Gallium 67 scintigraphy as a predictor of renal prognosis in primary immunoglobulin A nephropathy

From October 1987 to September 1989, 29 patients with newly diagnosed immunoglobulin A nephropathy underwent renal gallium 67 scintigraphy. The radioisotope uptake ratio between left kidney and soft tissue was measured 48 hours after bolus injection of gallium 67. In 25 patients the ratio ranged from 1.30 to 3.56 (mean, 1.95 +/- 0.47). Ratios were not obtained in four patients because strong gastrointestinal isotope excretion. Plots of reciprocal serum creatinine concentration against time and Kaplan-Meier plots of renal survival were used to assess the predictive value of the test in 20 patients for whom long-term follow-up data were available. The radioisotope uptake ratio was negatively correlated with the slope of reciprocal serum creatinine against time (r = -0.64, P < 0.01). When the 20 patients were divided into two groups according to radioisotope uptake ratio (group A, ratio > 1.95, nine patients; group B, ratio < 1.95, 11 patients), life table analysis of renal survival showed group B to have a better prognosis than group A (P < 0.05). The results indicate that increased renal gallium uptake is predictive of a poor prognosis in patients with immunoglobulin A nephropathy.

Congenital psoriasiform erythrokeratodermia with cleidocranial dysplasia, urogenital anomalies and atresia ani

We describe two siblings with unique psoriasiform erythrokeratodermia associated with cleidocranial dysplasia, urogenital anomalies and atresia ani. The skin lesions were characterized by demarcated psoriasiform erythema with scaling. A skin biopsy revealed small abscesses containing polymorphonuclear leukocytes in the parakeratotic horny layer, elongation of the rete ridges and dermal papillae, and other findings consistent with psoriasis. A reverse-transcription polymerase chain reaction analysis disclosed increased expression of transforming growth factor alpha in the affected skin lesion of one of the siblings as well as in the skin of a patient with psoriasis. It is suggested that these cases are a variant of a congenital form of psoriasiform erythrokeratodermia.

Myelofibrosis secondary to renal osteodystrophy

A hemodialyzed women with secondary hyperparathyroidism who recovered well from myelofibrosis after a total parathyroidectomy with autotransplantation of parathyroid tissue to the forearm (PTx) is described. Before the operation, she had received regular transfusions to maintain an adequate hematocrit even under recombinant human erythropoietin (rhEpo) therapy. She showed splenomegaly and leukoerythroblastosis was present in her peripheral blood. A bone marrow biopsy and bone marrow scintigraphy confirmed the diagnosis of myelofibrosis. After PTx, her hematocrit gradually increased without any transfusion. It has been maintained around 35% now 16 months since the operation. Her spleen has also gradually decreased in size. In addition, no leukoerythroblastosis has been found in the peripheral blood. Serial follow-up scintigraphy of bone marrow revealed a decline in extramedullary hematopoiesis. These findings indicated that her myelofibrosis was the result of secondary hyperparathyroidism, and that this complication is potentially reversible if accurate treatment is given. Physicians dealing with the end-stage renal disease should be aware of this complication to avoid additional transfusions.

A single-base mutation in exon 31 converting glycine 852 to arginine in the collagenous domain in an Alport syndrome patient

In a family with Alport syndrome, molecular analysis of the COL4A5 gene, which encodes the alpha 5(IV) chain of glomerular basement membrane collagen, revealed a GGA-->AGA change in exon 31, resulting in substitution of an arginine for a glycine in position 852 of the polypeptide chain, between interruptions 16 and 17 of the triple-helical collagenous domain. The mutation causes the MaeI restriction sites, and could be easily diagnosed in the family members through restriction analysis. This one point mutation can be expected to interrupt type IV collagen molecules.

[A case of renovascular hypertension with nephrotic syndrome]

A 68-year-old male patient with renovascular hypertension (RVHT) and nephrotic syndrome (NS) is described. He was admitted to our hospital for detailed investigation of severe hypertension and massive proteinuria. After admission, a diagnosis of RVHT with a right non-functional kidney and NS was made. Nephrectomy and contralateral renal biopsy were performed for refractory hypertension and detailed investigation of the NS, respectively. The renal biopsy showed focal segmental glomerulosclerosis (FGS) in the left kidney, whereas the nephrectomised kidney exhibited only ischemic change. After the operation, his blood pressure became stable without anti-hypertensive agents, but proteinuria remained in the nephrotic range. Six months later, proteinuria had disappeared and his renal function was stable. These findings suggest that NS and FGS might have resulted from an activated renin-angiotensin-axis and that the prolonged NS was due to severe glomerular injury. Although there have been many reports describing the relationship between RVHT and FGS in an experimental environment, this relationship is very rare in clinical cases. Therefore we present this case to increase understanding of the cause of FGS.

Case report: intraglomerular metastasis with neoplastic cell interposition

A case is described of an 88-year-old man with lung cancer, nephrotic syndrome, and renal dysfunction who died suddenly of an acute myocardial infarction and whose autopsy revealed many adenocarcinoma cells stacked within glomerular capillary lumina of his kidney, entering into basement membrane zones (ie, neoplastic cell interposition). In addition, glomeruli showed a lobular transformation, doubling of glomerular basement membrane, and electron dense deposits along the glomerular basement membrane. These changes were similar to those of membraneoproliferative glomerulonephritis. The association of intraglomerular metastasis and membranoproliferative glomerulonephritis-like lesions led the authors to speculate that the latter glomerular change might have provided an attractive opportunity for circulating tumor cells to be trapped and grow within the glomerular lumina. This mode of metastasis has not been well-recognized. The authors describe the experience, review the literature, and discuss its possible pathogenesis.

The attitude of Japanese physicians regarding genetic service for autosomal dominant polycystic kidney disease (ADPKD)

A questionnaire carried out among Japanese physicians revealed that a strong demand for genetic counseling among patients and families with autosomal dominant polycystic kidney disease (ADPKD). In contrast, the awareness of physicians regarding genetic counseling for the disease seemed to be low. For example, 66.0% of the respondents to the questionnaire revealed a negative attitude to providing genetic counseling for patients, and 30.7% of the respondents did not know that most types of polycystic kidney disease are inherited disorders. With the advance of scientific research, the demand for genetic counseling among patients is bound to increase. Therefore, the providers of genetic counseling including the physicians are now pressed to improve their services.

Renal hypouricemia: incomplete combined defect

A 20-year-old man with hypouricemia with markedly increased renal uric acid clearance is described. He also exhibited idiopathic hypercalciuria and lipoid nephrosis on hospital admission. Urate excretion was minimally suppressed by pyrazinamide and minimally increased after administration of probenecid, whereas it decreased after administration of benzbromarone. These results suggest that not only presecretory reabsorption, but also postsecretory reabsorption of urate was incompletely defective and indicate that the latter is more defective than the former. The relationship between hypouricemia and hypercalciuria or lipoid nephrosis in this case is not clear. However, since the hypouricemia persisted despite the remission of minimal change nephrotic syndrome, it appears that at least his nephrosis was incidental.

A kinetic study of the glomerular cells of developing and mature rat kidneys using an anti-bromodeoxyuridine monoclonal antibody

Newborn and mature Wistar rats received a single intraperitoneal injection of 5 bromo-2'-deoxyuridine (BrdU), a DNA precursor, to assess cellular proliferation by labeling S-phase cells. For immunohistochemical analysis, paraffin sections were prepared two hours after BrdU injection. The various stages of development of the glomeruli were observed within each newborn rat. The most primitive glomeruli were found close to the renal capsule, with progressively more mature glomeruli appearing in the deep renal cortex. BrdU-positive nuclei were frequently detected in the epithelia of nephrogenic vesicles, S-shaped vesicles and ureteral buds. When the capillaries invaded the S-shaped vesicles, the developing glomerular basement membrane was recognizable. In this and more mature stages of the glomeruli, presumptive podocytes no longer showed BrdU-positive nuclei, but they were easily detected in the mesangial and endothelial cells of the glomerular tufts. The mean labeling index of the glomerular tuft cells of mature rats was approximately 0.54%. The majority of labeled cells in the glomerular tufts were endothelial cells. Mesangial cells had a low labeling index. Podocytes revealed no evidence of proliferation. The labeling index of Bowman's epithelial cells, however, was approximately 0.71%, higher than that of the tuft cells. These findings may contribute to a better understanding of the mechanisms of cellular interplay within the glomeruli.

A splicing mutation in the alpha 5(IV) collagen gene of a family with Alport's syndrome

DNA sequence analysis of the alpha 5(IV) collagen chain gene (COL4A5) was carried out between exon 47 and 51, which encode the noncollagenous (NC) domain, in eight Japanese families with Alport's syndrome. In one family with X-linked inheritance of the disease, a point mutation (G to C) was found at the 3' end of exon 49 in the COL4A5. This mutation converted the codon of a conserved methionine-1601 to the codon for isoleucine, and also altered the normal splicing process. The polymerase chain reaction (PCR) product amplified between exons 47 and 51 of cDNA in the affected male (hemizygote) of this family contained four fragments with various molecular weights, whereas that of a normal control contained one with the expected molecular weight. Sequence analysis of the PCR fragments of the male patient revealed various types of alternative splicing between the exons, reflecting the various sizes of PCR fragments. The PCR amplified product of the cDNA of the affected female (heterozygote), on the other hand, contained a fragment with the same molecular weight as the normal control. Sequence analysis of the PCR fragments of her cDNA revealed normal splicing and no point mutation at the 3' end of exon 49. These findings indicate that this point mutation at the consensus sequence not only converted the codon but also altered the splicing between these exons encoding the NC domain of the COL4A5. Resulting in missense of the alpha 5(IV) chain, changing a large portion of the carboxyl terminal crosslinking NC domain, this mutation can alter the normal structure of the type IV collagen network.(ABSTRACT TRUNCATED AT 250 WORDS)

Page kidney with constrictive perinephritis

We describe a case of Page kidney following an infectious urinoma complicated by a pyelolithotomy. The most characteristic finding was the fact that this case resulted from constrictive perinephritis, not from any usual etiology such as perirenal hematoma. Knowledge of the patient's medical history and split venous renin measurements were helpful in making a diagnosis. She had refractory hypertension during conservative medical therapy. Finally, a nephrectomy improved her hypertension. The value of venous renin sampling for reaching a diagnosis, and the medical and surgical therapeutic options are discussed. This report also reviews all previously described cases of Page kidney without hematomas.